The moral, legal and ethical issues doctors face as they care for patients in the final weeks of their lives are being highlighted in a right-to-die case before the Supreme Court of British Columbia.
During cross-examination Tuesday, Douglas McGregor, regional medical director of palliative care for the Vancouver Coastal Health Authority, was asked about having to make the troubling life-or-death decisions concerning terminally ill patients.
Joseph Arvay, a lawyer trying to strike down a section of the Criminal Code that makes it illegal for physicians to assist in suicide, outlined a hypothetical case for Dr. McGregor in which a terminally ill patient begs to be heavily sedated, knowing it will be fatal.
In the scenario described by Mr. Arvay, a 73-year-old patient with a history of colon cancer has been diagnosed with tumours in his abdomen and bones. He is in intense pain and can't eat or drink because his body can't process what he ingests. Doctors conclude the only way to keep him alive is to insert a catheter into his spine – but the patient rejects the procedure and instead asks for palliative sedation, a heavy drugging technique used on the most extreme cases in palliative-care wards.
The court heard that palliative sedation is also called "slow euthanasia" because while it relieves intense pain, it also hastens death. It can be used only on those who are within days of dying.
In the case Mr. Arvay was outlining, the patient had months to live – and doctors had determined that palliative sedation would shorten the patient's life to days.
"What would you do?" he asked Dr. McGregor, whose duties include caring for terminally ill patients at Cottage Hospice in Vancouver.
"He's saying, 'I've had enough. I want to die now. Would you administer palliative sedation?" Mr. Arvay asked.
"Possibly. Yes," said Dr. McGregor, who several times paused to reflect on the difficult questions being put to him.
Later, Mr. Arvay presented medical research published recently that suggests the belief that palliative sedation ends all pain may be in doubt. He said heavily drugged patients are unconscious and unable to speak, but they may still be aware of their plight and suffer pain, distress and panic attacks.
Mr. Arvay asked, in the face of that evidence, if Dr. McGregor could promise patients that palliative sedation would end all suffering as they entered the final stage of their life.
"I'd have to think about that, for sure," said Dr. McGregor.
Mr. Arvay asked Dr. McGregor to imagine the courts had changed the law, making it legal for physicians to assist terminally ill patients in suicide. Under those circumstances, he asked, could a doctor honour his oath to only "do good" for a patient, by administering a lethal medicine to someone who was facing a slow, extremely painful, but certain death. Essentially, he was asking Dr. McGregor if, given different laws, a doctor might be ethically justified in helping a patient to commit suicide in the face of great suffering.
"Yes. But I'm not sure that is the right thing to be doing in our society," Dr. McGregor said.
George Copley, a lawyer for the B.C. Ministry of the Attorney-General, which opposes changing the Criminal Code on the issue, later asked Dr. McGregor to elaborate on that answer.
"I think, as physicians … we set out to value life above everything else … that is a value I will continue to hold and I don't think many of my colleagues would differ from that," he said.
Dr. McGregor said Vancouver hospices have about 110 to 120 deaths a year, most of which are relatively painless because of drugs and treatments used.
Over the past eight years, only about eight have been in such extreme pain they needed palliative sedation, he said.
The constitutional challenge to the Criminal Code is being brought by the B.C. Civil Liberties Association and several individuals, including Gloria Taylor, a 63-year-old woman with Lou Gehrig's disease who seeks to end her own life.
Ms. Taylor has not been in court. She is expected to testify Dec. 1.